Self-funded Employer’s Guide
Transitional Reinsurance Fee
and Patient-Centered Outcomes
Research Institute Fee
To fund some of the changes mandated by the Affordable Care Act (ACA), several new taxes and fees
will impact your group health plan. Two of these fees, the Transitional Reinsurance Fee and the PatientCentered Outcomes Research Institute (PCORI) Fee, are paid to the government directly by you.
While questions related to your specific situation should be directed to your tax advisor or legal counsel,
we would like to share an overview of the fees, information on remitting payment and the types of
coverage impacted by the fees.
The Reinsurance and PCORI Fees are both temporary and assessed on a per capita basis. That means
the fee is paid for each member or covered life (employees, spouses and dependents) under your health
plan. While both fees are paid annually, they have different schedules, fee amounts and exclusions.
Because the Reinsurance Fee, in particular, will have a financial impact on your business, we want to
share this information now so you have time to prepare for and fund this three-year fee.
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About the Transitional Reinsurance Fee
The ACA requires health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance
Program that will be in place from 2014 to 2016. Through the program, reinsurance fees are distributed to health
insurance issuers in the non-grandfathered individual market.The assumption is that the individual market,
which also includes health insurance purchased through individual Exchanges (also called Health Insurance
Marketplaces) may disproportionately attract individuals at risk for high medical costs. Reinsurance payments
will be made to reduce the uncertainty of insurance risk in the individual market by partially offsetting issuers’ risk
associated with high-cost enrollees.
Reinsurance Fees are collected by the Department of Health and Human Services (HHS) for each health plan that
meets minimum value. The fees are based on your enrollment count for the first nine months of the calendar year.
The reinsurance dollars will then be used by a reinsurance entity to make payments to eligible health insurance
issuers that offer health insurance through the individual market.
Transitional Reinsurance Fee Amount
The health reform law specifies the total amounts of the Reinsurance Fee that must be collected: $12 billion in
2014, $8 billion in 2015 and $5 billion in 2016, totaling $25 billion.
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In 2014, the Reinsurance Fee is $5.25 per member per month ($63 per member per year).
In 2015, the fee is $3.67 per member per month ($44 per member per year).
In 2016, the fee is yet to be determined.
States also may collect fees if they establish their own reinsurance program.
UnitedHealthcare must remit the Reinsurance Fee for its fully insured coverage, but our customers with selffunded plans are responsible for submitting their enrollment counts, funding and paying the Reinsurance Fee.
Transitional Reinsurance Fee Payment Schedule
The Reinsurance Fee may be submitted in one payment or in two installments. If submitting as one payment, the
full amount is due by Jan. 15. If paying in two installments, for the 2014 calendar year, of the $63 per member per
year rate, the first installment of $52.50 goes to reinsurance payments and administrative expenses and is due Jan.
15. The second installment of $10.50 goes to the U.S. Treasury and is due November 15, 2015.
Enrollment counts are determined based on the first nine months of the calendar year regardless of plan year or
renewal date. The enrollment count only needs to be submitted once per year.
Key Dates for the 2014 Reinsurance Fee
4 November 15, 2014
M
embership counts due to HHS
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4 January 15, 2015
The due date for making the first payment, if
paying in two installments. Last day to make
the full payment, if making one payment.
4 November 15, 2015
T
he due date for making the second
installment of the 2014 payment.
Submitting Membership Counts and Payment for the Transitional
Reinsurance Fee
The federal government issued guidance outlining how to submit the annual enrollment count to HHS:
• Use the form on Pay.gov (www.pay.gov), a web-based application where forms and online payments to
government agencies can be submitted.
• Provide basic company and contact information, the annual enrollment count for the applicable year and
upload supporting documentation.
• Pay.gov will auto-calculate the contribution amounts.
• Decide if you want to submit the Reinsurance Fee in one payment or two installments, and schedule payment
date(s).
• Payment will be automatically deducted from the designated account on the dates selected.
• Contact your bank and add Agency Location Code (ALC+2 value) 7505008015 to your list of approved
companies for ACH automatic debits. Failure to do this may delay your payment to the government.
• Submit the number of covered lives via pay.gov by Nov. 15.
Training on this process is available. Register on https://www.regtap.info/ to receive training notices.
See Calculating Your Membership Count for Either Fee to review the four counting methods.
The Department of Labor (DOL) has advised that payment of the Reinsurance Fee would be considered a
permissible expense of the plan under Title I of the Employee Retirement Income Security Act of 1974 (ERISA)
because the payment is required under the ACA.
The Internal Revenue Service (IRS) has indicated that a sponsor of a self-funded group health plan that pays
the Reinsurance Fee may treat the contributions as an ordinary and necessary business expense, subject to
disallowances or limitations under the Code. This tax treatment applies whether the contributions are made
directly or through a third-party administrator or administrative-services-only contractor.
Coverage Impacted by the Transitional Reinsurance Fee
The Reinsurance Fee is paid once per covered life on plans that provide major medical coverage and meet
minimum value, including grandfathered plans.
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The Reinsurance Fee does not apply to supplemental or secondary coverage including the following types of
coverage:
• Accident-only coverage
• Medicare Advantage plans
• Children’s Health Insurance Program (CHIP)
• Medicare supplement coverage that meets the
• Employee Assistance Programs (EAP) or wellness
requirements of Section 1882(g)(1)
• Part D prescription drug benefits
programs that do not provide major medical
• Plans covering tribal members and dependents (not
benefits
• Expatriate-only plans
employment-based plans)
• Flexible Savings Accounts within the meaning of
• Plans that do not meet minimum value
• Prescription drug benefit plans
Section 125 of the Code
• Health Reimbursement Arrangements that are
• Retiree-only plans that pay secondary to Medicare
• Stop loss
integrated with major medical coverage
• Health Savings Accounts
• TRICARE
• Indemnity reinsurance policy
• Specified diseases or hospital indemnity coverage
• Medicaid
• Stand-alone vision and dental (as long as they are
• Medicare
excepted benefits under HIPAA)
About the PCORI Fee
The Patient-Centered Outcomes Research Institute (PCORI) Fee helps fund research that evaluates and
compares health outcomes, clinical effectiveness, and the risks and benefits of medical treatments and services.
PCORI Fee Amount and Payment Schedule
Under the ACA, health insurance issuers and plan sponsors are responsible for paying the PCORI Fee. The fee
is in effect from 2012 to 2019. The PCORI Fee is assessed on each covered life (employees, retirees, spouses and
dependents).
Here is the fee schedule:
• For plan years ending on or after Oct. 1, 2012, and before Oct. 1, 2013, the fee was $1 per member per year.
• For plan years ending on or after Oct. 1, 2013, and before Oct. 1, 2014, the fee is $2 per member per year.
• For plan years ending in any fiscal year beginning on or after Oct. 1, 2014, the fee is indexed for
medical inflation.
• The fee will not apply to policy or plan years ending after Sept. 30, 2019.
Payment must be submitted by July 31 of the calendar year immediately following the last day of the plan year.
4 Case example: Calculating the PCORI Fee Using the Form 5500 Method
Next Level Logistics determined that it has 350 employees and 835 lives covered under its plan using the
Form 5500 method, after comparing the results of this count with other counting methods. Its plan year
runs from Oct. 1, 2012, to Sept. 30, 2013.
For Next Level Logistics, the $1 per member per year fee in the amount of $835 is due on July 31, 2014.
(Remember, if Next Level Logistics’s plan year ended on or between Oct. 1, 2012 to Dec. 31, 2012, the
PCORI Fee would have been due July 31, 2013.) The payment of the PCORI Fee is based on the date
the plan ends, not when it begins, and the fee must be filed on Form 720 by July 31 of the calendar year
immediately following the last day of the plan year.
Assuming Next Level Logistics still has 835 covered lives for the second year of the PCORI Fee ($2 per
member per year), a payment of $1,670 will be due on July 31, 2015.
Remitting the PCORI Fee
Unlike the Reinsurance Fee, you will not submit membership counts via pay.gov nor will you receive an invoice
or notice for the PCORI Fee. Instead, you’ll need to file federal excise tax return Form 720. Payment must be
submitted with the form by July 31 of the calendar year immediately following the last day of the plan year.
(Third-party administrators are prohibited under the health reform law from remitting the fee for you.)
The PCORI Fee is imposed on the plan sponsor, not the group health plan. For this reason, sponsors generally
may not pay the fee with ERISA plan assets, which includes participant contributions. But the DOL has indicated
that the board of trustees of a multiemployer plan (which has no other source of funding), as well as a voluntary
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employees’ beneficiary association (VEBA) providing retiree-only coverage, may use plan assets to pay the fee. This
is in contrast to the Reinsurance Fee, which is payable from ERISA plan assets.
The IRS stated that the PCORI Fee will be tax-deductible by employer groups (i.e., sponsors of self-funded group
health plans) as ordinary and necessary business expenses, subject to any applicable disallowances or limitations
under the Code.
Coverage Impacted by the PCORI Fee
The PCORI Fee applies to grandfathered, medical, pharmacy, retiree-only, any accident or health insurance
coverage (including a policy under a group health benefit plan) issued to individuals residing in the United
States. This fee does not apply to the following types of coverage (this list is different from the Reinsurance
Fee exclusions):
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Children’s Health Insurance Program (CHIP)
Employee Assistance Programs (EAP) or wellness programs
“Excepted benefits,” as defined under HIPAA, such as stand-alone vision or dental plans
Expatriate coverage (those working outside the United States and their spouses and dependents)
Flexible Spending Accounts, when they meet the excepted benefits test
Health Reimbursement Arrangements, when they meet the excepted benefits test
Health Savings Accounts
Indemnity reinsurance policies, where the reinsuring company accepts all or part of the risk of loss under the
policy and the issuing company retains its liability for covered lives
• Medicaid
• Medicare
• Stop loss, where the issuer is liable for all losses in excess of a specified amount and where the plan sponsor
retains its liability for losses
• TRICARE
• Federal programs for providing care to Indian tribes (other than through insurance)
Special Counting Rules for Multiple Self-funded Plans
If the plan sponsor of a self-funded plan has more than one self-funded plan (e.g., one for medical, another for
pharmacy) it may treat them as a single self-funded plan for purposes of these fees to avoid double counting of
the members.
If you have a flexible spending account (FSA), that is not an excepted benefit, or a health reimbursement
arrangement (HRA) and also have a fully insured medical plan, then you may treat each participant’s account as
covering a single life. The plan sponsor is not required to count spouses or other dependents. (The special rule
does not apply if you have another self-funded plan.)
If you have an FSA/HRA and also an applicable self-funded health plan (that is not an FSA or HRA), the
arrangements may be treated as one plan. In this case, the special counting rule for FSAs/HRAs would not apply.
These special counting rules apply only to self-funded plans.
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Calculating Your Membership Count for Either Fee
The IRS provides four counting methods for determining the number of members covered by your health
plan, and you may already have the information at your fingertips.
Remember that when determining the number of covered lives for the Reinsurance Fee, annual
membership counts are based on the first nine months of the calendar year regardless of plan year or
renewal date. For the PCORI Fee, covered lives are counted during the entire year.
Calculating the number of covered lives under your plan will directly affect the amount of your payment
for the Reinsurance and PCORI Fees, so it must be performed carefully. We recommend that you
calculate the number of covered lives under more than one counting method to determine the one that is
most favorable.
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With certain differences noted below, these methods may be used to calculate both the Reinsurance Fee and the
PCORI Fee. (A different counting method may be used for each fee.) You must use the same method consistently
for the duration of any year, but may use a different method from one plan year to the next. Many of you have
multiple plans, so it’s important to know that the same method must be used for all plans during the plan year.
1. Actual Count: Count the total covered lives for each day of the plan year and divide by the number of days in
the plan year. (For the Reinsurance Fee, you only count lives during the first nine months of the plan year; for
the PCORI Fee you count lives for the full 12 months of the year.)
2. Snapshot Count Method: Count the total number of covered lives on a single day in each quarter (or more
than one day) and divide the total by the number of dates on which a count was made. (The date or dates must
be consistent for each quarter. The Reinsurance Fee only looks at the first three quarters of the plan year.)
3. Snapshot Factor: In the case of self-only coverage and other than self-only (e.g., family or self-only plus
one) coverage, determine the sum of: (1) the number of participants (i.e., employees or retirees) with self-only
coverage, and (2) the number of participants (i.e., employees or retirees) with other than self-only coverage
multiplied by 2.35. The Snapshot Factor requires a minimum of four data points, once each quarter. The
timing should be generally consistent from quarter to quarter.
4. Form 5500 Method (Annual Return/Report of Employee Benefit Plan):
• For self-only coverage, determine the average number of participants by combining the total number of
participants at the beginning of the plan year with the total number of participants at the end of the plan
year as reported on the Form 5500 and divide by 2.
• For plans with self-only and other than self-only (e.g., family or self-only plus one) coverage the average
number of total lives is the sum of total participants covered at the beginning and the end of the plan
year, as reported on Form 5500.
More on Form 5500
• This may be the most accessible method for many private sector employers. Plan administrators of an
employee benefit plan subject to ERISA must file Form 5500 each year.
• It is generally filed by employers in the private sector with 100 or more employees. Small employers with plan
assets must also file Form 5500.
• Form 5500 only shows your number of participants, which are employees and/or retirees (not spouses
or dependents).
• State and local government plans (including tribal government plans), churches and tribal plans do not file this
form, so the Form 5500 method is not available to these groups.
• UnitedHealthcare does not have access to this form.
4 Case example: Estimating the Reinsurance Fee Using the Snapshot Count Method
Kevco Manufacturing counts its members on the first day of the first three quarters of the plan year.
January 1 1,989 members
April 1
1,882 members
July 1
1,990 members
-------------------------------------5,861 divide by 3
-------------------------------------
1,954
Average membership count for the first nine months of the year x $5.25 fee x 12 months = $123,102
estimated payment for 2014
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Membership Count Support
Here are three sources to find your membership count:
UnitedHealthcare will
provide a monthly
enrollment summary
report for each medical
plan you have with
UnitedHealthcare.
Your UnitedHealthcare
representative will provide
the report to you at no
charge in early October.
information when determining the number of lives covered under the health
plans.
2. Use Employer eServices*, if available to you. Find the membership
by month on Employer eServices under Reports, then Membership, then
click on Membership by Month report. Use the report to find membership
counts for either the Reinsurance Fee or the PCORI Fee. These numbers
can be used to determine the number of covered lives using the Snapshot or
Snapshot Factor methods.
3. Use UnitedHealthcare’s Reinsurance Fee membership report. Your
UnitedHealthcare representative will provide a monthly enrollment summary
report for each medical plan you have administered by UnitedHealthcare.
Membership Counts for
the Reinsurance Fee
The report will be:
• available in early October
• supplied at no charge
• aligned with the data requested by HHS
• representative of the data available to UnitedHealthcare
DuVail Industries has more
than 100 employees and is
subject to the Form 5500
filing requirement. Its plan
provides for family group
health plan coverage.
You can use this report to calculate your membership using the Snapshot
Method. Because the report only represents the data available to
UnitedHealthcare, we encourage you to compare these numbers to the
number of covered lives you have calculated for the Reinsurance Fee using
other counting methods, including Form 5500 if available to you.
4 Case Example: Comparing
Using the Snapshot Count
Method, it determined its
membership for the first
three quarters of the year
is 201, 250 and 265. The
average of these counts is
239. DuVail then contacts its
plan accountant and learns
that the participant count
(employees and/or retirees
only) on its prior year Form
5500 at the beginning of the
year was 105 and at the end
of the year was 115. The sum
of these two counts is 220.
Accordingly, DuVail Industries
elects to use the Form 5500
method for determining the
number of covered lives for
the Reinsurance Fee.
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1. Use your own membership data. Employers have the most accurate
It’s important to note that customers who are new to UnitedHealthcare may
not have nine months of membership data available. And, customers with
multiple health insurance carriers or third-party administrators will need to
contact them to find their true membership count.
UnitedHealthcare will not supply membership counts, outside of
Employer eServices, for the PCORI Fee. Although the membership counts
for the Reinsurance Fee are not due until Nov. 15, 2014, the PCORI Fee, on the
other hand, was due for many organizations by July 31, 2013. Most companies
will have made two annual PCORI fee payments before the first Reinsurance Fee
payment is due. In addition to different payment schedules, the PCORI Fee is
calculated based on the number of members for 12 months and the Reinsurance
Fee for nine months.
According to the health reform law, the employer is ultimately responsible for the
accuracy of the membership counts and payment of fees.
Why UnitedHealthcare Does Not Remit the Fees for You
The Reinsurance and PCORI Fees are based on your membership counts, and you are in the best position to
analyze which is the most cost-effective way to determine your membership count. The final rule also prohibits
third-party administrators from remitting the PCORI Fee on behalf of self-funded customers. Here’s why you,
and not your TPA, should determine the number of covered lives under your plan:
1. Variations in Plan Design: Sponsors of self-funded plans have flexibility in their plan design. This includes
benefit offerings from different issuers, HMOs and TPAs. Groups sometimes adopt policies that allow
members to freely transfer from one benefit offering to another. You are permitted to provide coverage to the
same employees through more than one group health plan simultaneously. Due to this flexibility, our data will
only represent a portion of your plan membership. Our membership count, while helpful, is not necessarily
sufficient to support a covered lives determination.
2. Coverage Considerations: Certain types of coverage are excluded from the Reinsurance and PCORI Fees.
Be sure to review your plan documents to determine if coverage is subject to the fee or if it does not meet
minimum value. Although UnitedHealthcare can share technical information about these fees, we are not in
the position to review your plan documents and provide legal advice.
3. Fluctuations in Employment: You may experience variations in staffing levels that will affect your
membership count. Although your human resource department is aware of these employment trends, we are
not. Normal employment fluctuations should be taken into account so you can effectively count covered lives
consistent with the health reform law. This may include seasonal workers, for example, when a retailer may
increase staffing in the fourth quarter to gear up for the holiday season.
4. Dependency Variables: There are variations under the approved counting methods. This variation stems, in
part, from the fact that Form 5500 only captures the number of participants (i.e., employees and retirees) and
not total covered lives. Due to this limitation, self-funded employers may extrapolate the number of covered
lives assuming a “rough” dependency factor of 2.0 (i.e., each employee will have one dependent). Although
ERISA customers with a high ratio of dependents per employee might benefit from use of the Form 5500
method, those with a low ratio of dependents per employee might not. For this reason, we suggest that you
compare figures using different counting methods.
5. Limitations of Form 5500: If Form 5500 is available, it is an important tool to be used when ERISA plan
administrators count covered lives. The Form 5500, however, may disclose information about ERISA welfare
benefit plans, which includes a range of benefits, including health, life, disability and death benefits. This
means that participants in non-group health plans may be comingled on Form 5500 with group health plan
participants. When determining your membership count, the plan fiduciary using the Form 5500 method
would need to coordinate closely with your accountants to determine which participants are disclosed on
Form 5500. (UnitedHealthcare does not have access to Form 5500.)
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Considering these factors, we encourage you to assess
your membership count and compare the figure using
more than one counting method. If you have questions
about the counting methods or submitting fee payment,
please contact your tax advisor or legal counsel.
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For more information
Consult your UnitedHealthcare representative if you have questions.
Visit the United for Reform Resource Center at uhc.com/reform
for the latest health reform news, educational videos, timelines and
frequently asked questions about health reform.
*This information is based upon UnitedHealthcare’s interpretation of the Snapshot Method of counting covered lives, which is one of four counting methods
approved by the IRS. It is also predicated on the eligibility information that the customer has provided UnitedHealthcare throughout the year.
Because UnitedHealthcare does not know whether a Snapshot count is the most appropriate method to be used for your group health plan, it is important
that you compare this Snapshot count with the results you may obtain under other available counting methods. Each of the different counting methods may
produce different results which will affect the amount of your fees.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare
Services, Inc., or its affiliates. This communication is not intended, nor should it be construed, as legal or tax advice. Please contact a competent legal or tax
professional for legal advice, tax treatment and restrictions. Federal and state laws and regulations are subject to change.
9/14 ©2014 United HealthCare Services, Inc.
UHCEW647324-002